Aplikasi Nanda, NOC dan NIC

Ns. Heni Dwi Windarwati, MKep.,SpKepJ

PROSES KEPERAWATAN

The Nursing Process

It is a systematic framework for the delivery of nursing care.It uses a problem-solving approach.It is goal-directed, its objective being the delivery of quality client care.It makes use of the nurse/Patient relationship

The Nurse/Client Relationship

What is it? The process by which the nurse provides care for the client in need of psychosocial intervention. We use ourselves.

The Goal of the Nurse Client Relationship

The relationship focuses on the needs of the client, has goals which are specific, is theory based, and is open to supervision.

ASSESSMENT

Definition of Asessment

A systematic, dynamic process by which the nurse , through interaction with the client, significant others, and healthcare providers, collects and analyzes data about client.

Include (ANA)– Physical– Psychological– Sociocultural– Spiritual– Cognitive – Functional abilities– Developmental– Economic– Life-style

Biopsychosocial Components:

The Stuart Stress Adaptation Model of psychiatric nursing care views human behavior from a holistic perspective that integrates biological, psychological, and sociocultural aspects of care.

The holistic nature of psychiatric nursing practice examines all aspects of the individual and the environment.

Faktor Predisposisi

Biologi Psikologi Sosialkultural

Stresor presipitasi

Nature Origin Timing Number

Penilaian terhadap stresor

Kognitif Afektif Fisiologis Perilaku Sosial

Sumber koping

Kemampuan personal Dukungan sosial Aset material Keyakinan positif

Mekanisme koping

Konstruktif Destruktif

Rentang respon koping

Respon adaptif Respon Maladaptif

DIAGNOSA KEPERAWATAN

Predisposing Factors:

Predisposing factors are risk factors that influence both the type and amount of resources the person can use to handle stress and are biological, psychological, and sociocultural in nature.

Biological predisposing factors include genetic background, nutritional status, biological sensitive, general health, and exposure to toxins.

Psychological predisposing factors include intelligence, verbal skills; morale; personality; past experiences; self-concept, motivation; psychological defenses; and locus of control, or a sense of control over one's own fate

. Sociocultural predisposing factors include age, gender, education, income, occupation, social position, cultural background, religious upbringing and beliefs, political affiliation, socialization experiences, and level of social integration or relatedness.

Precipitation Stressors:

Precipitating stressors are stimuli that are challenging, threatening or demanding to the individual. They require excess energy, and produce a state of tension and stress. They may be biological , psychological, or sociocultural in nature, and they may originate either in the person's internal or external environment.

Besides describing the nature and origin of a stressor, it is important to assess the timing of the stressor. A final factor to be considered is the number of stressors an individual experiences.

Appraisal of Stressor

Appraisal of a stressor involves determining the meaning of and understanding the impact of the stressful situation for the individual. It includes cognitive, affective, physiological, behavioral, and social responses.

Appraisal is an evaluation of the significance of an event in relation to a person's well-being. The stressor assumes its meaning, intensity, and importance as a consequence of the unique interpretation and significance given to it by the person at risk.

Coping Resources:

Coping resources are options or strategies that help determine what can be done as well as what is at stake. Coping resources include economic assets, abilities and skills, defensive techniques, social supports, and motivation. Other coping resources include health and energy, spiritual supports , positive beliefs, problem-solving and social skills, social and material resources, and physical well-being.

Coping Mechanisms:

Coping mechanisms are any efforts directed at stress management. The three main types of coping mechanisms are as follows: – Problem-focused coping mechanisms, which involve tasks and direct efforts

to cope with the treat itself. Examples include negotiation, confrontation, and seeking advice.

– Cognitively focused coping mechanisms, by which the person attempts to control the meaning of the problem and thus neutralize it. Examples include positive comparison, selective ignorance, substitution of rewards, and the devaluation of desired objects.

– Emotion-focused coping mechanisms by which the patient is oriented to moderating emotional distress. Examples include the use of ego defense mechanisms, such as denial, suppression, or projection. A detailed discussion of coping and defense mechanisms.

Coping mechanisms can be constructive or destructive.

DIAGNOSIS

Komponen dari Proses Keperawatan

NANDA: Nursing Diagnosis: Definitions and ClassificationNIC: Nursing Interventions ClassificationNOC: Nursing Outcomes Classification

Variations of Nursing Diagnosis’:

1. Actual diagnosis: describes health conditions that exist and supported by defining characteristics 2. Risk diagnosis: those which describe disease or other conditions that may develop and are supported by risk factors 3. Wellness diagnosis: describe levels of wellness and potential for enhancement to a higher level of functioning

(NANDA, 2009) and (Denehy & Poulton, 1999)

Components of a Nursing Diagnosis

1. Label or Name and definition2. Related Factors OR Risk Factors3. Defining Characteristics

Nursing Diagnosis

Terminology used by professional nurses that identifies actual, risk or wellness responses to a health state, problem or condition

Terminology used by professional nurses that identifies a person’s, family’s, or community’s motivation and desire to increase wellbeing and actualize human health potential

After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors. These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help.A nursing diagnosis may be an actual or potential health problem, depending on the situation.The most commonly used standard is that of the North American Nursing Diagnosis Association (NANDA)

Medical Diagnosis

Describes a disease or pathologyConditions MD treats MD cares for a pt with Congestive Heart Failure (CHF) – treats pathology with meds, oxygen, diet & fluid restriction

Nursing Diagnosis

Describes pt’s response to a health problem Situations RNs can treatNursing dx describe pt’s response to CHF: such as: Anxiety; Activity Intolerance, Impaired Peripheral Tissue Perfusion, Powerlessness

Types of Nursing Diagnoses

Actual nursing diagnoses: patient has problemRisk diagnoses: patient is at risk for developing the problem (Either begins with “Risk for” or the definition will include “is at risk for”)Wellness diagnoses: patient functioning effectively but desires higher level of wellnessOthers that you do not need to know:– Possible diagnoses– Syndrome diagnoses– Collaborative problems

Formulating the DiagnosticStatement

After identifying the best NANDA to describe your patient’s problem...You need to formulate a “diagnostic statement”– An actual diagnosis has a three-part statement– A risk diagnosis has a two part statement– A wellness diagnosis has a one part statement

Actual Diagnostic StatementThree-Part Format

Three parts:– NANDA label– Related factors (follows NANDA & linked by the

words “related to”)– Defining characteristics (follows related factors &

linked by the words “as manifested by”)

Actual Diagnostic Statement Example

Impaired Physical Mobilityrelated to (r/t) decreased motor agility and muscle weaknessas manifested by (AMB) limited ROM

“Impaired Physical Mobility r/t muscle weakness AMB limited ROM”

Risk Diagnostic StatementTwo-Part Format

Two parts:– NANDA label– Risk factors (follows NANDA label and is linked by

the words related to)

Risk Diagnostic StatementExample

Risk for Impaired Physical Mobilityrelated to (r/t) full leg cast

“Risk for Impaired Physical Mobility r/t full leg cast”

Wellness Diagnostic Statement

Used when pt doesn’t have a health problem but can attain higher level of healthIs a one part statement consisting only of the NANDA:– Readiness for Enhanced Parenting– Readiness for Enhanced Family Processes– Readiness for Enhanced Spiritual Well- Being

Case Study

Pengkajian

Pasien mengeluh – Pasien satu hari pasca operasi mengeluh nyeri– TD 130/90 mmHg– RR 30X/ menit– N: 115X/Menit– Nyeri skala 8– Ekspresi wajah tampak kesakitan– Mengeluh tidak bisa tidur

Langkah yang harus dilakukan:

Analisa data pengkajianData apa yang harus kita tambahkanBuat asumsi masalah yang terjadi pada pasienpilih domain masalah keperawatanPilih kelas dan tetapkan diagnosaCek di definisi, batasan karakteristik dan faktor yang berhubungan atau faktor resikoTetapkan diagnosa keperawatan.

Analisa Data

Data subjektif:– mengeluh nyeri– Mengeluh tidak bisa tidur

Data objektif– TD 130/90 mmHg– RR 30X/ menit– N: 115X/Menit– Nyeri skala 8 – Ekspresi wajah tampak kesakitan

Domain dan class– Nyeri akut domain 12: comfort class 3: social

comfort

Hasil– Masalah pasien adalah nyeri– Dengan 7 karakteristik– Faktor resiko karena luka operasi (injuri fisik)

– KESIMPULAN: NYERI AKUT

LATIHAN

• Seorang perempuan berusia 40 tahun mengeluh nyeri abdominal, malas makan dan diare. Dari hasil pemeriksanaan didapatkan penurunan berat badan dari 60 kg menjadi 45 kg. selain itu membran mukosa tampak kering dan lemah. Pasien mengatakan hal ini terjadi setelah peristiwa bencana di desanya 2 bulan yang lalu yang mengakibatkan dia bingung harus tinggal dimana.

• Tetapkan diagnosa keperawatannya

Analisa data

DS– Mengeluh nyeri abdomen– Malas makan

DO– Diare– Berat badan turun dari 60 kg menjadi 45 kg– Membran mukosa kering– Tampak lemah

Data yang ditambahkan: tidak adaAsumsi– Nyeri– Ketidakseimbangan Nutrisi: kurang dari kebutuhan

tubuh– diare

Domain dan class– Nyeri domain 12: comfort class 3: social comfort– Ketidakseimbangan Nutrisi: kurang dari kebutuhan

tubuh domain 2: nutrisi class 1: ingestion– Diare domain 3: elimination and exchange class

2: gastrointestinal function

Hasil

Hasil– Masalah pasien adalah Ketidakseimbangan Nutrisi:

kurang dari kebutuhan tubuh – Dengan 6 karakteristik– Faktor resiko karena stres psikologis

– KESIMPULAN: KETIDAKSEIMBANGAN NUTRISI: KURANG DARI KEBUTUHAN TUBUH

INTERVENSI KEPERAWATAN

Perawat dituntut berpikir sistematis dan kritisSMART: spesifik, measurable, achievable, rational dan timeline

Nursing interventions are treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient / client outcomes.

Writing a client plan of care

Two important concepts guide a client plan of care:

 1- The plan of care is client centered.

 2- The plan of care is a step – by step process.

 Sufficient data are collected to substantiate nursing diagnoses.

At least one goal must be stated for each nursing diagnosis

Outcome criteria must be identified for each goal

Nursing interventions must be specifically designed to meet the identified goal.

Each intervention should be supported by a scientific rationale.

Evaluation must address whether each goal was completely met, partially met, or completely unmet.

NURSING OUTCOMES CLASSIFICATION (NOC)

NOC

The nursing outcomes classification (NOC) is a classification of nurse sensitive outcomesNOC outcomes and indicators “allow for measurement of the patient, family, or community outcome at any point on a continuum from most negative to most positive and at different points in time.” ( Iowa Outcome Project, 2008)

Components

A neutral label or name used to characterize the behavior or patient statusA list of indicators that describe client behavior or patient status.A five point scale to rate the patient‘s status for each of the indicators

NANDA/NOC Linkage

Each nursing Diagnosis is followed by a list of suggested outcomes to measure whether the chosen interventions are helping the identified problemEach outcome can be individualized to the patient or family by choosing the appropriate indicators or adding additional indicators as necessary

Langkah Membuat NOC

Tetapkan diagnosa KeperawatanTetapkan NOC– Sugested: sering digunakan dan telah diriset– Additional: tambahan untuk melengkapi intervensi

keperawatan

Buka indeks sesuai outcome yang kita pilih– Indikator: hasil yang akan kita tuju– Skala:

Menuliskan tujuan– Setelah dilakukan …….selama 3 X 24 jam klien

dapat• Menjelaskan manfaat …… (5)• Menyebutkan keuntungan …. (3)

CASE STUDY

Pengkajian

Pasien mengeluh – Pasien satu hari pasca operasi mengeluh nyeri– TD 130/90 mmHg– RR 30X/ menit– N: 115X/Menit– Nyeri skala 8– Ekspresi wajah tampak kesakitan– Mengeluh tidak bisa tidur

Diagnosa nyeri akutSugested : pain level (alasan karena skala nyeri pasien adalah 8)Indikator– Melaporkan nyeri sedang (3)– Menunjukkan ekspresi muka terhadap nyeri sedang

(3)– Menunjukkan penurunan kegelisahan/ kemampuan

istirahat (3)– RR normal– N normal – TD normal

Cara penulisan– Setelah dilakukan program penurunan nyeri selama

3X24 jam pasien mampu• Melaporkan penurunan nyeri menjadi sedang (3)• Menunjukkan ekspresi muka dengan penurunan nyeri(3)• Menunjukkan penurunan kegelisahan/ peningkatan

kemampuan istirahat (3)• RR normal• N normal • TD normal

LATIHAN

• Seorang perempuan berusia 40 tahun mengeluh nyeri abdominal, malas makan dan diare. Dari hasil pemeriksanaan didapatkan penurunan berat badan dari 60 kg menjadi 45 kg. selain itu membran mukosa tampak kering dan lemah. Pasien mengatakan hal ini terjadi setelah peristiwa bencana di desanya 2 bulan yang lalu yang mengakibatkan dia bingung harus tinggal dimana.

• Tetapkan kriteria hasilnya

Diagnosa : KETIDAKSEIMBANGAN NUTRISI: KURANG DARI KEBUTUHAN TUBUH Sugested : nutritional statusIndikator:– Intake makanan oral (3)– Intake cairan oral (3)– Rasio berat badan (3)– Tonus otot (3)– Energi (3)

Untuk indikator nyeri dilihat pada sugested atau additional yang lain

Penulisan– Setelah dilakukan program pemenuhan kebutuhan

metabolik selama 3 X 24 jam pasien mampu• Menunjukkan intake makanan yang adekuat• Menunjukkan intake cairan yang adekuat• Menunjukkan peningkatan berat badan• Menunjukkan penurunan kelemahan• Menunjukkan peningkatan energi

NURSING INTERVENTIONS CLASSIFICATION (NIC)

Tindakan untuk menuju tujuanTanggung jawab dan tanggung gugat perawatHarus berdasarkan data dan diagnosa

NIC

“The nursing interventions classification (NIC) is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties.” (Iowa Intervention Project, 2008)

Interventions

Definition: “any treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.” (Iowa Intervention Project, 2000,p.3)

Components

Name or labelA definitionA set of activities the nurse does to carry out the intervention

NANDA/NIC Linkage

Each NANDA diagnosis is followed by a list of suggested interventions for resolving the identified problemInterventions and activities should be chosen to meet the individual clients needsActivities can be further individualized by adding client specific informationAdditional activities may be added if appropriate

Langkah Menetapkan intervensi

Tetapkan diagnosa keperawatanCari diagnosa yang sesuaiTetapkan intervensi prioritas dan tambahanPilih intervensi sesuai data dan diagnosaINGAT: harus sistematis

Pengkajian

Pasien mengeluh – Pasien satu hari pasca operasi mengeluh nyeri– TD 130/90 mmHg– RR 30X/ menit– N: 115X/Menit– Nyeri skala 8– Ekspresi wajah tampak kesakitan– Mengeluh tidak bisa tidur

Cara penulisan– Setelah dilakukan program penurunan nyeri selama

3X24 jam pasien mampu• Melaporkan penurunan nyeri menjadi sedang (3)• Menunjukkan ekspresi muka terhadap nyeri sedang (3)• Menunjukkan penurunan kegelisahan/ kemampuan

istirahat (3)• RR normal• N normal • TD normal

NICPilih domain comfortPilih manajemen nyeriPilih tindakan yang sesuai untuk indikator tersebut

• Kaji nyeri meliputi lokasi, karakteristik, durasi, frekuensi, kualitas, intensitas dan faktor pencetus nyeri

• Kolaborasi berikan analgesik• Ajarkan dan latih manajemen nyeri:

– relaksasi progresif– guided imajeri

• Berikan pendidikan kesehatan tentang manajemen nyeri• Evaluasi keefektifan manajemen nyeri

LATIHAN

• Seorang perempuan berusia 40 tahun mengeluh nyeri abdominal, malas makan dan diare. Dari hasil pemeriksanaan didapatkan penurunan berat badan dari 60 kg menjadi 45 kg. selain itu membran mukosa tampak kering dan lemah. Pasien mengatakan hal ini terjadi setelah peristiwa bencana di desanya 2 bulan yang lalu yang mengakibatkan dia bingung harus tinggal dimana.

• Tetapkan dintervensi keperawatannya.

Pilih domain nutrisiPilih – manajemen berat badan– Konseling nutrisi

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